Patient Medical History Form Page 6

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Patient Name
Date:
:
REVIEW OF SYSTEMS
Please circle any problems you are currently experiencing
CONSTITUTIONAL
decreased appetite  faintness  dizziness  headache  fever  difficulty breathing when lying flat
feeling as if room is spinning  weakness  unexplained weight loss  unexplained weight gain 
NONE
CARDIOVASCULAR
chest or arm pain  blood clots  cramps in legs or feet when walking  high blood pressure  low
blood pressure  heart attack  heart murmur  heart palpitations  stroke 
varicose veins 
mitral valve prolapse  NONE
MUSCULOSKELTAL
joint ache or pain  chronic neck pain  chronic hip pain  chronic low back pain  chronic ankle
pain  stiffness  morning stiffness  weakness  pain in the feet in the morning  pain upon
rising anytime  swelling of joints  limited motion in joints  cramps in legs or feet when sleeping
 NONE
INTEGUMENT
allergy to chemicals  scarring  dry skin  itchy skin  cracking skin  thick or discolored
toenails  thick or discolored fingernails  skin rash  scarring after surgery or injury  skin cancer
pain associated with skin  NONE
NEUROLOGICAL
tingling  pins and needles  numbness  increased sensitivity to touch  burning  decreased or
lack of sensation to touch  shooting pain  decreased or lack of sensation to heat or cold  radiating
pain  NONE
ENDOCRINE
increase or decrease in thirst  increase or decrease in urination  diabetes mellitus  thyroid
problems  post-menopause  NONE
HEMATOLOGICAL/LYMPHATIC
hemophilia  anemia  bruise easily  blood transfusion reaction  leukemia  sickle cell disease
or trait  weakness  yellow discoloration of the skin  NONE
Patient Signature__________________________________________ Date________________________
Physician Signature _______________________________________ Date _______________________
Created: 4/27/10 KM (updated 04.27.12)
O:formslibraryPatient Forms/Form_Medical History-detailed- Yellow.doc
6 
 

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